Page 23 - ABM 2021 Benefit Guide MGT
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DENTAL BENEFITS
Whether or not you join the medical plan, you may
enroll in dental coverage administered through MetLife Dental PPO
MetLife. ABM has made some modernization ABM ofers team members two dental plans. You can
ind out how a dental procedure will be covered in
changes to the dental beneits. Please see below advance. Ask your provider for a predetermination of
for an overview of the plan design.The percentages beneits to estimate plan coverage and out-of-pocket
shown in this table are the amounts the plan pays. costs.
Premium Dental Standard Dental With the MetLife plans, you can receive care from
any provider; however, you will receive a higher level
In-Network
In-Network
Calendar Year Deductible of beneit if you stay in-network. Even though the
Individual $25 $50 reimbursement percentages are the same for in- and
Family $75 $150 out-of-network services, out-of-network providers do
Calendar Year Maximum not agree to discounted fees which can make out-
$3,000 per person $1,500 per person of-network usage more expensive. Out-of-network
Coinsurance charges are subject to reasonable and customary
Preventive—Type A 100% no deductible 100% no deductible charges. Download the free apps from the App Store
SM
Basic—Type B 70% after deductible 70% after deductible (or Google Play for Android ) by searching MetLife.
TM
Major—Type C 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $2,500 $1,000
Beneit Applies To Adults and children Adults and children
Visits and Exams
Limitations 2 per year 2 per year
Prophylaxis, 100% no deductible 100% no deductible
including Scaling
and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years 1 per every 3 years
to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
ABM 23
Whether or not you join the medical plan, you may
enroll in dental coverage administered through MetLife Dental PPO
MetLife. ABM has made some modernization ABM ofers team members two dental plans. You can
ind out how a dental procedure will be covered in
changes to the dental beneits. Please see below advance. Ask your provider for a predetermination of
for an overview of the plan design.The percentages beneits to estimate plan coverage and out-of-pocket
shown in this table are the amounts the plan pays. costs.
Premium Dental Standard Dental With the MetLife plans, you can receive care from
any provider; however, you will receive a higher level
In-Network
In-Network
Calendar Year Deductible of beneit if you stay in-network. Even though the
Individual $25 $50 reimbursement percentages are the same for in- and
Family $75 $150 out-of-network services, out-of-network providers do
Calendar Year Maximum not agree to discounted fees which can make out-
$3,000 per person $1,500 per person of-network usage more expensive. Out-of-network
Coinsurance charges are subject to reasonable and customary
Preventive—Type A 100% no deductible 100% no deductible charges. Download the free apps from the App Store
SM
Basic—Type B 70% after deductible 70% after deductible (or Google Play for Android ) by searching MetLife.
TM
Major—Type C 50% after deductible 50% after deductible
Orthodontia
Coinsurance 50% after deductible 50% after deductible
Lifetime Maximum $2,500 $1,000
Beneit Applies To Adults and children Adults and children
Visits and Exams
Limitations 2 per year 2 per year
Prophylaxis, 100% no deductible 100% no deductible
including Scaling
and Polishing
Fluoride 100% no deductible 100% no deductible
Limitations 2 per year 2 per year
Sealants 100% no deductible 100% no deductible
Limitations 1 per every 3 years 1 per every 3 years
to 14 to 14
X-Rays
Bitewing X-Rays 100% no deductible 100% no deductible
Limitations 2 per year to 19, 1 2 per year to 19, 1
per year thereafter per year thereafter
Full Mouth X-Rays 100% no deductible 100% no deductible
Limitations 1 every 5 years 1 every 5 years
Endodontics
Root Canal 70% after deductible 70% after deductible
Minor Restorations
Amalgam (silver) 70% after deductible 70% after deductible
Fillings
Composite Fillings 70% after deductible 70% after deductible
(anterior teeth only)
Stainless Steel 70% after deductible 70% after deductible
Crowns
Crowns 70% after deductible 70% after deductible
Full and Partial 50% after deductible 50% after deductible
Dentures
Denture Repairs 70% after deductible 70% after deductible
Notes Beneits are calendar year
To look for a provider to learn more about this coverage; visit:
metlife.com/mybeneits.
ABM 23
